Limiting Patient Harm Due to Acute Kidney Injury

Background

A team at South Tees Hospitals NHS Foundation Trust in Middlesbrough developed a programme to raise awareness of Acute Kidney Injury (AKI) and to recognise and treat the condition promptly. Since the programme started there has been a sustained reduction (36%) in AKI cases within the surgical wards at Middlesbrough. Now this successful programme and pathway has been shared with 7 other trusts in the North East of England and been consulted by several other NHS Trusts (Imperial, Frimley Park, Wexham Park, North Devon, St Helen’s, Lincoln, Yeovil, Bartholomew’s, The Royal London and Southend). The Trusts were made aware of the AKI project through their links to CRAB Clinical Informatics Limited (C-Ci)

The South Tees Hospitals NHS Foundation Trust team was shortlisted for a national Patient Safety Award in which they were highly commended in July 2017.

Aims, Objectives and Scope

Acute Kidney Injury (AKI) is the term used when a person suffers from a sudden reduction in their kidney function. The name suggests an actual physical injury to the kidneys but this is misleading, in fact AKI usually occurs as a complication of another illness, such as infection. It is essential that AKI is detected early and treated quickly. Without prompt treatment, toxins can build up in the body, which affect the ability of other organs to work properly. If the kidneys shut down completely then dialysis may be needed and patients may even die.

In the UK, up to 100,000 deaths each year in hospital are associated with AKI. Up to 30% of AKI cases associated with death could be prevented with the right care. The costs to the NHS of acute kidney injury (excluding costs in the community) are estimated to be between £434 million and £620 million per year. (Source: NICE – https://www.nice.org.uk/guidance/cg169/chapter/introduction)

In 2009, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) AKI report (Adding insult to injury) alerted Trusts across the country that there were widespread deficiencies in AKI care. South Tees Hospitals NHS Foundation Trust participated in the original study and realised they faced a number of challenges common to all AKI intervention programmes:

They did not know the true incidence of AKI, particularly among surgical inpatients.

They were not aware of which risk factors contributed most to AKI incidence.

AKI awareness across all clinical departments was limited.

There was inconsistency in the detection and treatment of AKI across different wards

“The dedicated work and enthusiasm of a huge range of staff has improved and sustained AKI awareness, detection and management within the Trust”Dr Jonathan Murray, Consultant Nephrologist and AKI Lead for South Tees Renal Unit

Actions

A National AKI electronic alerting system was incorporated within the Trust pathology system

A 12-month intensive Trust-wide AKI awareness campaign was delivered including delivery of AKI education to multidisciplinary staff including pharmacy and healthcare staff at 54 dedicated one hour workshops

A teaching package was also developed to highlight harm caused by AKI and to ensure that training was consistent. A patient video was also used to highlight the harm of AKI.

Clinician AKI guidelines were developed and endorsed by the Regional Renal Network to unify AKI care across all wards.

An Advanced Nurse Practitioner (ANP) was appointed and received further training including prescribing, this was part of a longer term sustainable plan which ensured the Nurse was accessible and visible on wards, this is unique as there are only 5 renal nurses working this way across the country.

A Clinical Quality Assurance Platform was implemented to enable patient level co-morbidities to be tracked, including AKI incidence across different clinical areas within the Trust.

Measurement

Prior to the work commencing the team measured the incidence of AKI in their wards, levels were found to be similar to national averages.

In addition, unbeknown to the team, an independent evaluation was also taking place across the hospital by CRAB Clinical Informatics Limited (C-Ci). Crab were monitoring clinically important outcomes such as sepsis and AKI across the trust. Crab approached the AKI team to ask about their work. The crab measurement uses clinical coding to measure the monitored levels of AKI across wards and they found a reduction.

Results and Evaluation

In addition to the reduction in patient harm, South Tees NHS Foundation Trust estimates the AKI programme has saved the Trust £533,000 per year (£4500 saving per patient, 119 episodes p/a)

The incidence of AKI on surgical wards in South Tees NHS Foundation Trust was measured by an independent clinical informatics team (CRAB Clinical Informatics Limited) that collects clinically important data across many hospital Trusts. Their results showed that AKI incidence across surgical wards fell by 36% at the time of the AKI Awareness Programme and remains reduced at this level 8 months after the AKI Programme finished. Prior to the AKI Programme, the Trust’s AKI incidence was similar to national levels

Clinician and Nursing AKI guidelines were developed and linked to an AKI detection system that rapidly highlights possible AKI cases to ensure consistent AKI care across all wards, the AKI guidelines were endorsed by the Regional Renal Network to extend such consistent AKI care across other Trusts in the region

An AKI teaching package and patient experience video were developed to raise awareness of AKI and the new guidelines.

The team delivered AKI training to 272 multidisciplinary healthcare professionals via 54 small group AKI workshops, to empower staff to promptly address AKI within their own clinical areas. In addition, in other areas 122 medical trainees, 111 staff from City Hospitals Sunderland and 270 staff from The Newcastle Hospitals NHS Foundation Trust were trained.

An Advanced AKI Nurse Practitioner was appointed and trained to support AKI care outside of the Renal Unit.

Other adverse patient outcomes (eg. Cardiac arrest) also reduced following the AKI intervention, which may indicate earlier AKI detection enabled identification of deteriorating patients and also led to effective changes to patient care.

Benefits

To patients: Reduced risk of harm from AKI whilst in hospital. Reduced stay in hospital

Learning Points

It can be difficult to engage with the right staff, those who really need to be targeted, therefore a variety of methods were used for contact (email, business cards, whatsapp – even one of the team wearing a stuffed kidney around the hospital!)

Staff were emailed and advised that the NHS recommends staff awareness of AKI, many clinical and medical directors attended but the message also needed to filter to those more likely to deal with Aki on a day to day basis such as junior doctors.

Culturally AKI is not top of the list and could be perceived as someone else’s problem, only with education and the visible continuity of the nurse practioner were the team able to overcome this

Measurement of AKI is notoriously difficult as another condition is usually present

The team collaborated with their education centre who provided a learning environment away from the ward where staff had space to think and learn; they also provided certificates of attendance.

Plans for Spreading Learning and Encouraging Adoption

The South Tees Hospitals NHS Foundation Trust team have been helping other Trusts across the country to adopt the AKI programme. This Patient Safety Collaborative programme has currently been rolled out to 7 other Trusts across the North East and National adoption and spread of the programme could significantly reduce patient harm and NHS costs due to AKI. The ability to reduce potential patient harm from AKI has led to the team being shortlisted for a national Patient Safety Award.

Commonly AKI commonly starts in the community so the team is now focusing on strategies to support Primary Care to reduce AKI in the community and to harmonise AKI aftercare between hospital and community services.

Top Tips:

Use various techniques to engage HCPs.

Make it fun.

Make it relevant.

Concentrate on wards where the risk is high but the AKI culture is low as this will result in a wider impact.